Michael Edward Daugherty, MDGeneral Surgery
2925 Four Pines Dr, Lexington, KY 40502
- General Surgery
- Univ Of Ky Coll Of Med, Lexington Ky 40536, 1966
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Healthlynked Authorization Release of Information
I, authorize Dr. Michael Edward Daugherty to release any and all healthcare information about me to my HealthLynked personal health record (PHR) for my own uses and purposes. I acknowledge that such healthcare information may include the following: x rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information.
I acknowledge that with this authorization Dr. Michael Edward Daugherty may disclose any information or records (within the scope of the authorization) that Dr. Michael Edward Daugherty has received about me from other healthcare practices, providers or facilities. Dr. Michael Edward Daugherty may, within its discretion, withhold from disclosure any of the above information as permitted or required by law.
Access to treatment or services may not be denied to me if I decline to sign this Authorization or revoke my Authorization. However, without this Authorization, my Dr. Michael Edward Daugherty will not electronically release my healthcare informat io n to my HealthLynked PHR. I may revoke this authorization at any time. Such revocation will take effect immediately to the extent that my doctor has already acted based on this Authorization.
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Signed on: 2021-02-24 18:15
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